ARIZONA STATE UNIVERSITY



ARIZONA STATE UNIVERSITY

College of Nursing

NUR 559

History and Physical Assessment: The Pediatric Client

KIDS ARE DIFFERENT!

I. Health History - interview both parent and child to gather data, consider cultural differences, and individual parental differences.

A. Biographical information - essentially same as adult

B. Chief complaint or client's request for care

1. Frequently for wellness care

2. Brief statement of why seeking care and how long illness has occurred.

C. Present health status or present illness

1. If healthy - statement about usual health

2. If ill use 8 criteria to explore and describe chief complaint

D. Past history

1. Prenatal history

a. Mother's health while pregnant

b. Prenatal care

c. Mother's feelings during pregnancy

d. Any complications - i.e. hypertension, nausea, bleeding and etc.

e. Medications taken during pregnancy

f. Use of cigarettes, street drugs, alcohol, during pregnancy

2. Birth history

a. Duration of pregnancy

b. Parity of mom

c. Nature and duration of labor

d. Type of delivery

e. Use of sedation/anesthesia

f. Birth weight

g. Condition of baby at birth - any special procedures

3. Postnatal history

a. Any problems first days of life - i.e. skin color, respiratory distress, birth injuries, congenital abnormalities, difficulty sucking or gaining weight etc.

b. Age of infant at discharge

c. Any treatments/medications

4. Past illness

a. Childhood illnesses - include communicable diseases. Be specific.

b. Injuries

c. Hospitalizations

d. Operations

e. Other major illnesses

f. Frequency of infections

5. Adolescent History

a. Depression

b. Suicide

c. Drugs

d. Alcohol

e. Sexuality

f. Be sure he/she knows that what he/she tells you is confidential unless there is a chance for physical danger; encourage to always talk with parents.

6. Allergies

a. Environmental

b. Ingestion

c. Drug

d. Other

e. Remember allergies may change as child grows

7. Immunizations - be specific and record dates

a. DPT - #1 - 2 months

#2 - 4 months

#3 - 6 months

#4 - 15 or 18 months

#5 - 4 to 6 years

b. TD - adult type - 14 to 16 years and repeat every 5 years

c. Polio #1 - 2 months

#2 - 4 months

#3 - 12-18 months

#4 - 4 to 6 years

d. MMR (measles, mumps, rubella)

1. Give at age 12-15 months unless outbreak of measles present

2. Do tuberculin skin testing before MMR because of hazard of possible exacerbation of undiagnosed, untreated tuberculosis

3. 4-6 years of age or 11-12 years of age

4. Varicella 12-18 months and 11-12 years

e. Hib - Hemophilus influenza B conjugate vaccine

1. Give at 2 mo, 4 mo, 6 mo and 12 or 15 months

2. Do not give after age 5

3. Important for children in day care

f. Tuberculin skin test - at 9 months to 1 year and repeat at 2 years and 8 years and etc.

g. Hepatitis B

1. Give B-1 birth -2 months

2. Give B-2 1-4 months

3. Give B-3 6-18 months, 11-12 years

8. Habits

a. Alcohol

b. Tobacco

c. Drugs

d. Coffee, tea

e. Do not hesitate to ask - provide education and counseling

9. Medications taken regularly - prescribed and OTC

E. Developmental Data

1. Use screening tools

a. DDST

b. Temperament screening

c. Neonatal Behavioral Assessment Scale

d. Denver Articulation Screening Examination

e. Use developmental theorists - i.e. Piaget, Erickson, etc.

2. Determine age child attained specific developmental achievements

a. Held head erect

b. Rolled over

c. Sat alone

d. Walked alone

e. Said first word

f. Used sentences

g. Controlled feces

h. Learned urinary continence

3. Use tools to compare child's development with others

4. Find out if any periods of decreased or increased growth

5. Explore school achievement and/or problems

F. Nutritional Data

1. Early infant (birth to 6 months)

a. Type of feeding - breast or bottle - type of formula

b. Frequency of feeding

c. Amount consumed - each feeding and in 24 hours

d. Any changes in feeding - i.e. breast to bottle

e. Feeding problems and appetite, reaction to feedings

f. Any supplements - vitamins, iron, fluoride

g. Solid foods - none needed before 6 months

h. Water - encourage

2. Later in infancy (6 to 18 months)

a. Use of cup, spoon, finger feeding - needs to use spoon to help develop speech muscles

b. Solid foods

1. Fruits, vegetables, cereal first

2. No eggs, orange juice, desserts until after 1 year of age. Many discourage meat until after one year old

3. One new food at a time for 5 to 7 days

3. Preschool and older

a. Typical day - get specific

b. Likes/dislikes

c. Eating habits

d. Analyze using basic 4 and etc.

G. Family history

1. Use list of diseases as did with adult

2. Genogram

H. Review of Systems- ask questions as in adult but also include these additions

1. General

a. Explore weight gain/loss fully

b. Behavior changes

2. Integumentary System- Ask about family history of skin disorders, birthmarks, and any rashes. If rashes ask about lifestyle of family and any recent changes,

3. HEENT Systems

4. Ears- family history of hearing problems, maternal infections during pregnancy, problems during labor and delivery, and neonatal jaundice. Be alert and explore if any history of convulsions or head injuries. Ask about number of ear and upper respiratory infections, any surgery to ears, and prolonged use of any ototoxic drugs.

5. Eyes- Ask if child sits close to TV, or is clumsy, or has difficulty seeing board at school. In infants ask if child blinks when sees approaching objects. Inquire about family history of eye diseases, vision problems and color blindness. Inquire about excessive tearing and/ or no tears and about any discharge from eyes.

6. Mouth and Throat- Inquire if child has frequent sore throats, epistaxis, allergies, hay fever, or thrush. Ask about dental history- age of teeth eruption and number at one year. Family or child history of cleft palate or cleft lip,

7. Respiratory System- Ask parent about history of cough, wheezing, fever, shortness of breath, meningeal signs, abdominal pain, vomiting, sore throats, and any past respiratory diseases. Inquire about family history of respiratory disorders, caregiver smoking, type of childcare setting, and immunization status.

8. Cardiovascular system- Ask if any problems feeding, if an infant, undue fatigue, poor weight gain, reduced tolerance for exercise, cyanosis, edema, dizziness, epistaxis, squatting, frequent respiratory tract illness, murmurs and/or delayed development. Significant Family/Maternal history includes GABHS, systemic lupus, kidney disease, maternal age at birth > 40, toxemia of pregnancy, diabetes, use of lithium, and other drugs; and exposure to rubella. Also ask if family history of sibling congenital defects, hypertension, xanthomas, rheumatic fever, and myocardial infarction

9. Gastrointestinal System- ask about family history of gastrointestinal or genitourinary tract disorders. Be alert that maternal history of poly hydramnios is associated with intestinal atresia. Other important factors are history of imperforate anus, failure to pass meconium, cleft palate or lip, difficulty feeding, prolonged jaundice or abdominal wall disorders. In older children ask if child has anorexia, vomiting, or if engages in fasting or dieting and bowel habits. Inquire about tendency to bruise. If child complains about frequent abdominal pain- explore stressors. If child is a toddler, ask about toilet training progress.

10. Reproductive System- Document date of menarche, dietary and exercise habits. Parental concerns.

11. Neurological System- Inquire about family history of genetic disorders earning disabilities, and birth defects. Inquire about history of recurrent headaches, seizures, irritability and hyperactivity.

II. Sociologic System

A. Relationship with family and significant others

1. Position in family - adopted?

2. Lives with who?

3. With whom relates - is primary caretaker, baby sitting, friends

4. Recent family crises

B. Environment - same as adult history

1. Be sure to explore hazards

C. Occupational history - if appropriate

D. Economic status and resources

1. Explore parent's occupation and income

2. Effect of child's illness on parents' economic status

E. Educational level - same as adult. Explore school, grade and any school problems

F. Daily profile - same as adult

1. Remember play is social activity

2. Determine if parent feels there are any behavior problems

G. Pattern of health care

1. Same as adult

2. Frequency of wellness care - at ages 2 months, 4 months, 6 months, 9 months, 1 year, 15 months, 18 months, 2 years and yearly after age 2.

III. Psychological System - includes parent and child responses since parent in responsible for care - same as adult history.

A. Cognitive capabilities

B. Response to illness and health

C. Cultural implications

PEDIATRIC COMPREHENSIVE HISTORY ASSIGNMENT:

The Comprehensive Pediatric History assignment including the Denver Development Screening will be done outside of class with any child not your own, who is between 3 months and 6 years of age. The purpose is to give you the opportunity to interview a parent and obtain complete data. In the clinical setting, you will usually not have enough time to elicit the complete history and do a complete Denver Assessment; however, you will need to review histories that parents have already written and ask additional questions. Pediatric physical exams will be done later in your clinical assignments using the appropriate forms in the setting and copies submitted for review.

Please type your complete history and interpretation of the Denver Developmental screening. Attach the Denver Screening form.

Include the following from the History and Physical Assessment: The Pediatric Client in your syllabus..

1. Items A- C. 12

2. Past History 28

a. Prenatal

b. Birth History

c. Postnatal History

d. Past illness

e. Allergies

f. Immunizations

g. Habits

3. Developmental Data

a. Denver Developmental Screening 10

b. Developmental Milestones 10

4. Nutritional Data 5

5. Family History 10

a. List of diseases

b. Genogram

6. Review of Systems 25

TOTAL POINTS 100

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